Partnership working: taking targets a la carte

The 198 national indicators will tear up the 'set menu' of national targets, so local partnerships can tailor priorities to local needs. But regulation of the system will need a rethink

When you go to a Chinese restaurant with family or friends it seems natural to settle on one of the set meals. After all, management knows best and when the meal comes the only questions left are chopsticks or forks, tea or alcohol. Simple, sorted. But sometimes do you yearn to go a la carte?

Well, after years of only management-knows-best set meals being available in the form of top-down priorities, local authorities and the NHS are moving into an era of together choosing priorities and actions which best suit their local communities.

Whitehall priorities have often been resented as "not quite right here"- in one sense a form of nimbyism. As national primary care director David Colin-Thome says, if you were not concentrating on access, coronary heart disease, cancer, diabetes and mental health what else would you be doing? But here is an opportunity to do what is right for your community.

Last November the government published 198 national indicators that local authorities and their partners, through local strategic partnerships, will use to select up to 35 priorities and agree their targets and plans with government offices. All the wicked issues that can make or break a community and its quality of life and that have to be solved by local statutory agencies working in partnerships are included, from antisocial behaviour to improving local biodiversity.

The Department of Health complemented this approach at the end of January through the publication of "vital signs". There are some must-do national priorities (tier one) like 18-week waits; a set of national priorities which will be subject to local targets (tier two) like obesity among primary school children and then a raft of indicators for possible local priorities (tier three) such as the proportion of adults with learning disabilities who are in settled accommodation.

The point is that nearly all the tier two and three DH indicators are part of the 198 national indicators (think Venn diagrams and you have got it). Indeed, over 40 of the 198 are directly related to health and well-being, with some more which are indirectly related. They all require strong partnerships between the NHS, local authorities and others to make progress.

So as in the Chinese restaurant, the choice is potentially very wide, assuming you have the appetite once the must-dos are out of the way. The choices and the actions have to be agreed collectively.

This could be hard - many a group that has started going through the individual dishes has compromised on the set meal. My experience of the early stages of health action zones was that their members struggled at first to develop a sequence which started with the identification of need, went on to a clear priority expressed in outcome terms and finished with a set of actions which seemed likely to deliver the outcome. But they learned and times have moved on so it may prove easier.

The other point is that partners have to work for each other. It cannot all be about health and well-being. The NHS has traditionally focused on its own business and has been reluctant to get involved more widely. That is not an option if partnerships are to work and the quality of life for local people is to improve. So there are many areas that are not listed in the DH's "vital signs" where health services will have a part to play (people falling out of work and onto incapacity benefit), some where they should (like the emotional health of children in care and child protection) and some where the NHS, as one of the largest industries in town, needs to pull its weight (for example carbon dioxide emissions).

New standards

If the national and local approaches are changing, the regulatory and assessment system has to follow suit. It is a system built on individual inspectorates assessing individual institutions delivering to set national requirements. But now the institutions have to work together and locally tailored priorities mean nationally set requirements are no longer the be-all and end-all. The inspectorates therefore have to change their game. We need to work together to look at how partnerships are improving the quality of life for people in their area. We need to do this in a way which is less burdensome. And we must do it in a more helpful, forward-looking way.

These points are the very essence of comprehensive area assessment - seven inspectorates working together, pooling information, reporting on the national indicator set and providing an annual area risk assessment about the prospects for the area and the quality of life for local people.

This assessment will embrace primary care trusts. It will include some existing aspects of assessment. For example there will continue to be a use of resources assessment for individual PCTs, just as there will for local authorities and police authorities, although the approach will be different from the auditors' local evaluation. And the Healthcare Commission and its intended successor the Care Quality Commission will undertake periodic assessments of both PCTs and providers. But it will be a new world and building it is not going to be straightforward.

The Audit Commission and its partner inspectorates have just finished consulting on key aspects of CAA. The commission has also been consulting on the new approach to use of resources assessments. The consultation included nine regional roadshows attended by 160 people from PCTs and we have also been providing action learning in several communities around the country.

I have come away from the events with some important points. There is general support for what we are trying to do. The logic is right. The idea of a locally tailored risk assessment produced jointly by the inspectorates and focusing on the prospects for an area and the quality of life for the people in it is seen as generally the right approach. Views differ on whether and how a risk assessment should be scored. And as usual a real desire to move on to the next stage and to see the detail - what input will actually be required from individual bodies and will it be genuinely less not more burdensome.

There have been concerns from local government in particular about the scope and weight of the new style use of resources assessments, although PCTs have been less critical. PCTs seem generally to have welcomed the move to focusing more on outcome and less on process and that the assessment will be less about narrow aspects of financial management and more genuinely about use of resources.

There are concerns that the goalposts should not keep moving, that there should be strong continuity between the current and new approaches, that the workload certainly should not increase and that we ensure consistency of judgement. There has also been a very strong plea that use of resources judgements, the annual health check and the development of the world class commissioning framework are properly aligned.

We now need to address these points and ensure CAA and use of resources judgements do the job intended in a way that helps progress on the ground and does not overburden those who will be delivering it. We are committed to working closely with the Healthcare Commission and the DH to ensure the assessment system and the world class commissioning framework do not fall over each other. We just have to get it right.

New faces

The next few months will see some intensive work. Local strategic partnerships will be drawing up their priorities from the long list of possibilities and getting their local area agreements signed off. We and our partner inspectorates will be focusing on the detail in the light of the consultation and the action learning. There will also be a further round of consultation on the risk assessment and other aspects of CAA in the summer.

There will be some new faces too. We have restructured our resources within the Audit Commission to create new posts to lead CAA locally in partnership with the other inspectorates, making possible a continuous knowledgeable dialogue between members of local strategic partnerships and someone who is familiar with their problems and can help make judgements.

The groundwork for CAA will start for real towards the end of this year, with the first risk assessments delivered in the autumn of 2009 and I am looking forward to it. It is a different approach, one that is much more suited to the needs of local communities and can match the variety of local circumstances and local choices which PCTs and their partner agencies face.

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay